Saturday, December 03, 2005

When deciding where to spend their professional lives, doctors are faced with a basic decision about the type of patient they wish to see. It breaks down like this:

Type 1SuburbanHighly educatedWhiteHealthyHigh SESOvertreated

Type 2UrbanUndereducatedNon-whiteSickLow SESUndertreated

Of course this is a gross oversimplification, and many patients are a mixture of the two, but as a generality it's pretty accurate. Most doctors will say that they prefer to see a "good mix" of patients, but that's hard to achieve; Type 1 patients don't feel comfortable in offices where Type 2 patients hang out, and vice versa. In addition, when most doctors say they want a mix, what they really mean is that they want mainly one type, but with a smattering of the other thrown in to keep things interesting.

Me, I love taking care of the Type 2s; the Type 1s can drive me nuts. I can't stand having to explain to a Type 1 why this or that test or treatment isn't indicated, but I adore cajoling Type 2s into getting the tests and treatment they desperately need. And I'm good at it. I do have a mix of patients, mainly because people know that I have relatively fancy credentials, and therefore assume that I must be a Type 1 doctor.

Now, it seems to me from my web travels that the vast majority of people on the blogosphere fall squarely into the Type 1 column (the commenters more than the bloggers). If there's a test for something, everyone should get it. Because it would be absolutely terrible for someone to have a medical condition that isn't diagnosed and treated, right?

Well, not necessarily. I think of it as being kind of like the justice system. In the U.S., we'd overall prefer to let a few guilty people go free than to ever imprison an innocent person. In China, the opposite is true (at least from what I've read on the topic). Both systems have their pros and cons. We're horrified to hear about the innocent people imprisoned, possibly tortured, and put to death in China (or at least I am). But I bet they're horrified to hear about people being raped, tortured, and murdered by criminals who were released because of a lack of evidence. In both instances, innocent people suffer and die.

In medicine, testing people for illnesses that they are unlikely to have results in, essentially, false arrests and convictions; people suffer side effects of the tests themselves, and side effects of treatment for a something they may not even have, or if they do have, might never have harmed them. But allowing illnesses to go undetected will result in some people suffering from the illness itself.

There are many studies that examine this very thing, the cost:benefit ratio of a given test or treatment. It's tricky, because you have to put a price on priceless things — health, life — but it can be done. From studies such as these come recommendations about who should be tested. But what you'll find if you compare recommendations to actual practice is that the Type 1s get way more done to them than recommended, while the Type 2s get way less.

For instance: my mother is 65 and in a monogamous (er, I assume) relationship of 25 years. Yet every year, year after year, she gets a Pap smear done. When her risk of cervical cancer is zero. Why does her gynecologist keep putting her up in the stirrups? Well, for one thing, her insurance covers it, but more importantly, her gynecologist probably assumes that my mother expects and wants it. And because, well, yes, her risk is probably zero, but it's better to be safe than sorry, right? Right?

But what would happen if my mother had an abnormal Pap smear? More tests and procedures. Possibly endangering her. And definitely wasting a lot of resources. All for nothing, because if she had an abnormal Pap smear, it would be because of a test error. Who still dies of cervical cancer in this country? Yes, the Type 2s. Because they don't have insurance, or if they do, they don't have doctors who take their type of insurance -- or they don't have doctors, period.

The same thing goes for all the healthy people who get cholesterol tests every year. Or diabetes tests. Or, like my father-in-law, a stress test. The amount of money that is wasted on this kind of nonsense is truly shameful. If my mom could donate her Pap smears even every other year to someone who isn't getting them, a lot of good could be done. (I get a Pap smear every three years. Unfortunately I haven't found a way of donating the ones I don't use.)

There's an annoying saying in medicine that you should treat every patient as if she were your grandmother. I would phrase it a little differently: you should treat your grandmother the way you treat all of your patients, because all of your patients should receive not "VIP" care, but appropriate care.

12 comments:

As a hospital social worker, I have had plenty of cause to consider this topic. I totally agree with you.

I don't know what you think, but I'm guessing that a lot of doctors are afraid of the "liability" if they miss something -- i.e. if they only do a PAP once every three years. In my experience, so many patients have the victim mentality (contributed to by the power dynamic between pt and doctor). And, of course, so many of us feel helpless over many medical conditions.

Your description of "Type I" and "Type II" patients is interesting, too. My doctor practices out of a clinic that really does have a good mix of both types (the Type I's are more hippy-ish, so more tolerant of the the Type II's), and I enjoy it. I can't claim that I always feel comfortable sitting in the waiting room, but I think its good for me.

Guess I have a lot to say about this! Sorry to be so lengthy. Just found your post thought-provoking.

That is such a hard issue, isn’t it? On a purely intellectual level, I agree with you 100%. On a person and selfish level, I don’t. At 39 my sister presented with all the classic symptoms for colon cancer, but due to her gender and age she was not tested. At 40 she was diagnosed with stage 4 colon cancer, and was dead by 41. Maybe if they routinely screened people for colon cancer she would be alive today – who knows. It’s so hard to know what is right.

nancy, how awful. I'm so sorry about your sister.I don't of course know what happened with your sister, but the recommendations for screening apply only for asymptomatic people; when symptoms arise, it becomes an issue of diagnosis. We certainly do colonoscopies on 39 year olds with symptoms. But if we routinely screened young people with no risk factors for or symptoms of colon cancer, we would end up killing more people with the testing -- literally -- than we would save with the screening.You illustrate an important point: it feels different on a personal level -- which is why I take issue with "treat everyone like your grandma" -- we can make strange choices when it becomes personal.

This can all get even more confusing when someone crosses boundaries. I have bipolar disorder, which makes practioners assume I'm in the type II group. However, I have a master's degree in a healthcare field and am well informed about my own health issues as well as any testing someone asks me to get. In addition I live in rural Appalachia, so you see whatever doctor you can see. However, to meet my needs I searched out someone willing to work with me. I told him upfront that I will question things and will only work with him when we are working together to meet my needs. (ie I refused to get a seperate blood draw for a baseline cholesterol when I have 6 month blood draws done anyway; I will not go off the 3 year Pap schedule without someone giving a good reason). He does, but it's been funny to see him try to remember to accomodate for my not fitting his prototypical bipolar patient profile. He automatically started to prescribe something once because it was "medicaid preferred"; when reminded I have good insurance I got time release which is important for compliance for me. He also was amazed at my ability to chart bp readings over time and give him pertinent data.

On the other hand my psychiatrist is a high cost, able to pick patients, big city doctor. Everything is totally different with her. She makes sure everything prescribed is covered, but she assumes that I have an advanced level of understanding and am able to have educated opinions about my treatment.

What an interesting entry. I had never given much thought to the risks of medical tests themselves, except maybe too many x-rays or amnios, that sort of thing. I personally am a Type I who has often been in a Type II situation of being un- or underinsured, something more and more otherwise Type I's are experiencing these days, I imagine.

as a med student I'm learning patterns such type 1 and 2, and it's a bit dis-illusioning. I've only been in the hospital for a few months, but that's long enough for me to look at how I treat people of varying backgrounds. I've tried to step back and look objectively at what advice the attendings are passing on to me (is it "real" and valid or simply their opinion?) but it's hard when I'm tired and feeling overworked.

(I've made a mental note of your residency application advice and vow to be memorable. I'm in a unique situation and am spending my year where I hope to be a resident but I'm sure I'll interview other places.)

I'm glad to have stumbled onto your blog - it's wonderful to read about a doctor who is a nursing mom! (nice to know that it's possible...)

I'm mostly a type 1 but I've taken my daughter to a doctor's office that mostly treats type 2's. (They were the only dermatologists that didn't have at least a month-long waiting list.) It wasn't the other patients that bothered me, it was the fact that the receptionist talked to everybody like they were dogs, me included, and the nurse I had to deal with assumed I didn't have any sense. Type 1's don't put up with that sort of thing, and maybe type 2's don't think they have any choice. Maybe they really don't have any choice. The doctors were cool, though.

Your blog is interesting and well written. I am enjoying it and felt the need to comment. I am the worse kind of type one because no one in my family dies of natural causes or makes it to age 60. I am not forty and I have had cervical cancer, two lumps removed from my breasts, meningitis, a tumor removed from a sinus, gall bladder removal, and part of my jaw removed because of an infection from some bad dental work. I don't smoke, or drink and I exercise regularly. It is interesting to me that for years I was treated as a type two at our local rural clinic because I was a very young looking single mother who was quiet and didn't speak up during visits to the doc for routine well child visits and my own occasional sinus/ear infection.When my health problems started in my thirties it was amusing to the docs/nurses how I became so more knowledgeable 'overnight' about surgical procedures and medications. They like to blame the Internet for that.

really? NO risk if you're monogomos and had healthy paps most of your life? Then why did my in-laws good friend get cervical cancer? (type 1, wealthy, 4 kids, monogomos, Christian-didn't have sex before marriage-kind of person) Is HPV the ONLY way to get abnormal cells resulting in cervical cancer?

love your blog by the way, and I know you posted this ages ago, but I still wanted to comment.